Evaluation of the optimal duration of immunosuppressive treatment after induction of remission, in patients with ANCA vasculitis

ISRCTN ISRCTN13739474
DOI https://doi.org/10.1186/ISRCTN13739474
Secondary identifying numbers 1
Submission date
04/01/2017
Registration date
10/01/2017
Last edited
30/05/2017
Recruitment status
No longer recruiting
Overall study status
Completed
Condition category
Circulatory System
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data

Plain English summary of protocol

Background and study aims
Vasculitis is a condition in which the immune system attacks blood vessels by mistake, leading them to lead fluid into tissues causing inflammation (swelling). This happens because antibodies, which are normally produced by the immune system to fight germs, start attacking a type of white blood cell called neutrophils. In the case of ANCA vasculitis, the antibodies which are attacking the neutrophils are called Anti-Neutrophil Cytoplasmic Autoantibodies (ANCA). When ANCAs attack the neutorphils, the neutrophils in turn start to attack the walls of small blood vessels in different parts of the body. The treatment of ANCA vasculitis is by drugs which suppress the immune system (immunosuppressive drugs). These drugs, which include steroids, have side-effects and it is desirable to reduce the doses and stop them where possible. However vasculitis can return when the drugs are reduced or stopped. The aim of this study is to investigate how long immunosuppressive drugs should be given to patients with vasculitis.

Who can participate?
Adults with ANCA vasculitis which has been treated and is now under good control.

What does the study involve?
Participants are randomly allocated to one of two groups. In both groups, before they are allocated to the different groups, participants are taking immunosuppressive therapy, which involves taking the drug azathioprine and prednisolone every day by mouth for three months. Those in the first group then stop taking the azathioprine and lower the dose of prednisolone, which is stopped altogether by five months later. Those in the second group continue to take their azathioprine until the end of the study (30 months) and gradually reduce and eventually stop taking their prednisolone between 18 and 24 months. At the start of the study and then every three months until the end of the study (30 months), participants attend visits where they have blood samples taken to find out whether the vasculitis has come back and to assess their health.

What are the possible benefits and risks of participating?
Not provided at time of registration

Where is the study run from?
1. Addenbrooke's Hospital (UK)
2. Hôpital Cochin (France)
3. Maastricht University (Netherlands)
4. Universitetssjukhuset Linköping (Sweden)
5. Uniklinikum Aachen (Germany)
6. Provicial Barcelona Hospital Hospital Clínic de Barcelona (Spain)

When is the study starting and how long is it expected to run for?
January 1994 to September 2012

Who is funding the study?
European Community (EC) BIOMED-1 Concerted Action Programme (UK)

Who is the main contact?
Prof. Alexandre Karras
alexandre.karras@aphp.fr

Contact information

Prof Alexandre Karras
Scientific

Hôpital Européen Georges-Pompidou
Nephrology Department
20 Rue Leblanc
Paris
75015
France

ORCiD logoORCID ID 0000-0002-3075-7739
Phone +33 (0)1 56 09 37 60
Email alexandre.karras@aphp.fr

Study information

Study designProspective open-label randomised controlled trial
Primary study designInterventional
Secondary study designRandomised controlled trial
Study setting(s)Hospital
Study typeTreatment
Participant information sheet Not available in web format, please use the contact details to request a patient information sheet
Scientific titleRandomised controlled trial comparing relapse rate between standard (18 to 24 months) and prolonged (48 months) immunosuppression with azathioprine and prednisolone, in patients in the remission phase of ANCA vasculitis
Study acronymREMAIN
Study objectivesProlonged maintenance therapy with low-dose prednisolone and azathioprine reduces long-term morbidity in systemic vasculitis, by reducing the frequency of relapse, when compared with cessation of therapy in the second year, as suggested by current guidelines.
Ethics approval(s)NHS Executive North West MREC, 07/03/2001, ref: MREC/00/8/74
Health condition(s) or problem(s) studiedANCA-associated vasculitis
InterventionPatients with ANCA vasculitis in stable remission are included 18 to 24 months after initiation of immunosuppressive therapy. Patients are randomised in a 1:1 ratio to either withdraw from immunosupprssion (Group W) or continue immunosuppression (Group C). Prior to randomisation, immunosuppressive therapy involves oral azathioprine at a daily dose of 1 mg/kg and oral prednisolone at the dose of 7.5 mg/day.

Group W: Participants receive oral azathioprine at the dose of 0.75 mg/kg for 3 months and then stop this drug. In addition, prednisolone is tapered to 5 mg/day at randomisation and then progressively stopped before month 5.

Group C: Participants continue oral azathioprine at the daily dose of 1 mg/kg for 30 months, until end of study. In addition, oral prednisolone is tapered to 5 mg/day at month 3, and then continued until month 18. After month 18, prednisolone is progressively stopped, before reaching month 24.

Duration of follow-up for both arms will be 30 months, with evaluation (examination and blood tests) every 3 months.
Intervention typeDrug
Pharmaceutical study type(s)
PhasePhase IV
Drug / device / biological / vaccine name(s)1. Azathioprine 2. Prednisolone
Primary outcome measureRate of vasculitis relapse is measured using the Birmingham Vasculitis Activity Score (BVAS) continuously from baseline to 30 months.
Secondary outcome measures1. Incidence of major and minor relapse is measured using the Birmingham Vasculitis Activity Score (BVAS) continuously from baseline to 30 months
2. Mortality rate is measured continuously from baseline to 30 months
3. Adverse events of therapy are observed continuously from baseline to 30 months
4. Cumulative damage is assessed using the Vasculitis Damage Index (VDI) from baseline to 30 months
5. Renal function is assessed by measuring estimated Glomerular Filtration Rate (eGFR) from baseline to 30 months
6. Incidence of end-stage renal disease (ESRD) is monitored from baseline to 30 months
7. ANCA status
Overall study start date01/01/1994
Completion date01/09/2012

Eligibility

Participant type(s)Patient
Age groupAdult
Lower age limit18 Years
SexBoth
Target number of participants116
Key inclusion criteria1. Diagnosis of MPA, GPA or renal-limited vasculitis
2. Renal involvement and/or other threatened loss of function of a vital organ (lung, brain, eye, motor nerve, or gut); and ANCA positivity (ANCA-negative patients were eligible for enrollment in the study only when there was histologic confirmation of pauci-immune vasculitis)
3. Remission-induction therapy with cyclophosphamide and prednisolone for at least 3 months, with or without plasma exchanges
4. Stable remission on azathioprine/prednisolone
5. Aged 18 years and over
Key exclusion criteria1. Age under 18 years
2. Pregnancy
3. Previous malignancy
4. Known HIV infection
5. Previous life-threatening relapse
6. End-stage renal disease (ESRD) at inclusion and allergy to study medications. Patients not in stable remission for at least six months at 18 months after commencement of therapy and patients who had discontinued azathioprine and/or prednisolone are excluded from the study.
Date of first enrolment01/09/1998
Date of final enrolment01/03/2010

Locations

Countries of recruitment

  • Czech Republic
  • England
  • Finland
  • France
  • Germany
  • Italy
  • Lithuania
  • Netherlands
  • Spain
  • Sweden
  • Switzerland
  • United Kingdom

Study participating centres

Addenbrooke's Hospital
Lupus and Vasculitis Clinic
Hills Road
Cambridge
CB2 0QQ
United Kingdom
Hôpital Cochin
Department of Internal Medicine
27 Rue du Faubourg Saint-Jacques
Paris
75014
France
Maastricht University
Department of Immunology
Minderbroedersberg 4-6
Maastricht
6211 LK
Netherlands
Universitetssjukhuset Linköping
Department of Nephrology
Universitetssjukhuset
Linkoping
581 85
Sweden
Uniklinikum Aachen
Department of Nephrology
Pauwelsstraße 30
Aachen
52074
Germany
Provicial Barcelona Hospital Hospital Clínic de Barcelona
Nephrology Department
Carrer de Villarroel, 170
Barcelona
08036
Spain

Sponsor information

European Vasculitis Society
Research organisation

Box 57
Department of Renal Medicine
Addenbrooke's Hospital
Cambridge
CB2 2QQ
United Kingdom

Website http://www.vasculitis.org/

Funders

Funder type

Research organisation

European Community (EC) BIOMED-1 Concerted Action Programme

No information available

Results and Publications

Intention to publish date31/12/2017
Individual participant data (IPD) Intention to shareYes
IPD sharing plan summaryAvailable on request
Publication and dissemination planPlanned publication in a high-impact reviewed journal.
IPD sharing planThe datasets generated during and/or analysed during the current study are/will be available upon request from Alexandre Karras (akarras3@gmail.com) or David Jayne (dj106@cam.ac.uk)

Study outputs

Output type Details Date created Date added Peer reviewed? Patient-facing?
Results article results 01/10/2017 Yes No

Editorial Notes

30/05/2017: Publication reference added.